A study of the relationship between the study process ...

Nurse Education Today 48 (2017) 13–18

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A study of the relationship between the study process, motivation resources, and motivation problems of nursing students in different educational systems☆ Figen Yardimci, PhD, RN a, Murat Bektaş, PhD, RN, Associate Professor b, Nilay Özkütük, PhD, RN c, Gonca Karayağız Muslu, PhD, RN d, Gülçin Özalp Gerçeker, PhD, RN b,⁎, Zümrüt Başbakkal, PhD, RN, Professor a a

Ege University Faculty of Nursing, Pediatric Nursing Department, Bornova, Izmir, Turkey Dokuz Eylül University Faculty of Nursing, Pediatric Nursing Department, Izmir, Turkey c Ege University Faculty of Nursing, Bornova, Izmir, Turkey d Muğla Sıtkı Koçman University, Fethiye Health School, Pediatric Nursing Department, Fethiye, Muğla, Turkey b

a r t i c l e

i n f o

Article history: Received 2 January 2016 Received in revised form 8 September 2016 Accepted 21 September 2016 Available online xxxx Keywords: Study process Motivation resources and problems Nursing students Educational systems

a b s t r a c t Background: The study process is related to students' learning approaches and styles. Motivation resources and problems determine students' internal, external, and negative motivation. Analyzing the study process and motivation of students yields important indications about the nature of educational systems in higher education. Objectives: This study aims to analyze the relationship between the study process, and motivation resources and problems with regard to nursing students in different educational systems in Turkey and to reveal their effects according to a set of variables. Design: This is a descriptive, cross-sectional and correlational study. Settings: Traditional, integrated and problem-based learning (PBL) educational programs for nurses involving students from three nursing schools in Turkey. Participants: Nursing students (n = 330). Methods: The data were collected using the Study Process Questionnaire (R-SPQ-2F) and the Motivation Resources and Problems (MRP) Scale. Results: A statistically significant difference was found between the scores on the study process scale, and motivation resources and problems scale among the educational systems. This study determined that the mean scores of students in the PBL system on learning approaches, intrinsic motivation and negative motivation were higher. A positive significant correlation was found between the scales. Conclusions: The study process, and motivation resources and problems were found to be affected by the educational system. This study determined that the PBL educational system more effectively increases students' intrinsic motivation and helps them to acquire learning skills. © 2016 Published by Elsevier Ltd.

1. Introduction The study process has an important role in students' lives. It means that each student uses a unique way to prepare, learn, and remember new and difficult information. It can also be expressed as a students' tendency to search for meaning, memorize information, and succeed based on their intention to learn. Some students try to find and form a

☆ The authors report no actual or potential conflicts of interests. Acknowledgment no external or intramural funding was received. ⁎ Corresponding author. E-mail addresses: fi[email protected] (F. Yardimci), [email protected] (M. Bektaş), [email protected] (N. Özkütük), [email protected] (G.K. Muslu), [email protected] (G.Ö. Gerçeker), [email protected] (Z. Başbakkal).

http://dx.doi.org/10.1016/j.nedt.2016.09.017 0260-6917/© 2016 Published by Elsevier Ltd.

meaning, this process can be described as deep learning, while others try to memorize the subject without associating it with other subjects. Still others try to learn with the intention to succeed without finding and forming meanings (Biggs et al., 2001). Studies on this subject show that the study process of students varies according to their intentions (Ekinci, 2009; Richardson, 2003; Mansouri et al., 2006; Snelgrove, 2004). The study process may also include variables such as the students' previous education, features of the teaching and learning environments where they study, their epistemological beliefs, critical thinking, and academic success levels and grades (Andreou et al., 2014; Richardson, 2003; Gijbels and Dochy, 2006; Ekinci, 2009). Motivation is a key for success and well-being. Motivation provides self-awareness to individuals by stimulating them (Gelona, 2011). It is also defined as a power that activates, maintains and directs goal-

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F. Yardimci et al. / Nurse Education Today 48 (2017) 13–18

oriented behavior. Motivation is a prerequisite in the learning process and an important factor in academic success (Acat and Köşgeroğlu, 2006; Köşgeroglu et al., 2009). Motivation is said to be related to such results as learning, performance, curiosity, and continuity in education. Therefore, educators should determine the relationships among motivation, academic success and learning and the factors that affect those subjects (Yoshida et al., 2008). Motivation resources and problems include internal, external and negative motivation (Acat and Köşgeroğlu, 2006). They can be classified as intrinsic motivation, extrinsic motivation and amotivation according to Ryan and Deci (2000). In intrinsic motivation, the main reason for performing the specific task is the individual's pleasure and satisfaction; whereas in the extrinsic motivation, the individual performs an action to get important results for him/her or for extrinsic award. Motivation problems emerge when individuals are unable to bring about a connection between their situations and the task or activity to be undertaken. This is defined as negative motivation or amotivation. Factors such as experiencing the effort of learning, seeing themselves as inadequate, being under pressure and having a fear of failure cause motivational problems in students. Motivation is one of the preconditions of learning. A student who is not motivated sufficiently is not ready for learning and therefore not using learning approaches (Ryan and Deci, 2000). 2. Background Problem-based learning (PBL), integrated, and traditional educational programs are used in nursing education. PBL education is based on empirical learning organized around solving and analyzing complex real-life problems. PBL education represents learning based on real-life that requires both the active intellectual participation of individuals and the use of their skills (Hung et al., 2007; Yuan et al., 2011). The integrated model is based on holistic learning. It leads individuals to see the big picture instead of learning small pieces, and associates topics with each other as a subject or problem (Fulmer et al., 2011; Sroczynski et al., 2011). Integrated nursing educational programs are basically structured from the viewpoint of health to illness by including basic knowledge, attitude, and skills of relevant subject fields. This program was intended not only to improve students' nursing-care skills using a systematic and bio-psychosocial approach, but also to help students to acquire skills such as effective communication, empathy, critical thinking, and problem solving (Şengül, 2010). Traditional programs primarily use the classroom lecture format and are usually non-interactive. This allows large amounts of information to be conveyed in a short time (Brown et al., 2008). Teachers of nurses must have knowledge about the study process of their students. Determining which deep and superficial approaches students use during studying will contribute to creating effective-learning environments. Teachers should have information about the learning approaches which are being used because this will provide an opportunity to take steps toward helping students with superficial-learning approaches to use deep-learning approaches (Yılmaz and Orhan, 2011). The study process includes deep and superficial learning approaches (Snelgrove, 2004; Snelgrove and Slater, 2003). Many studies have addressed the attitudes of nursing students toward learning approaches (Alkhasawneh et al., 2008; Al-Kloub et al., 2014; Andreou et al., 2014; D'Amore et al., 2012; El-Gilany and Abusaad Fel, 2013; Fleming et al., 2011; James et al., 2011; Li et al., 2008; Tiwari et al., 2006). Bengtsson and Ohlsson (2010) studied motivation and determined that students do not know where to concentrate their attention. They suggested educators should use different learning approaches and kinds of feedback for motivation. Mclaughlin et al. (2010) found that the personal development of students increases their desire to care and the emotional support of their family helps them achieve academic success and professionalism. Khalaila (2015) found a relationship between motivation and academic success. Braten and Olaussen (1998) identified a relationship between students' learning approaches and their

motivational beliefs. These findings suggest that this study can provide important data toward enhancing the quality of nursing education. This study aims to analyze the relationship between the study process, motivation resources, and motivational problems of nursing students in different educational programs in Turkey and to reveal their effects using a set of variables. This objective prompted the research questions: • Is there a difference between the educational systems, study process, and motivation resources and problems? • Is there a relationship between the study process, and motivation resources and problems? • What factors affect the study process, and motivation resources and problems?

3. Methods 3.1. Design and Sample A descriptive survey design was used to explore the nursing students' perceptions of the study process, and motivation resources and problems and the relationships between them. This study was conducted with three nursing schools that each use one of the following systems: the PBL, the integrated educational system, and the traditional educational system. The sample size was calculated using stratified sampling. The number of samples was homogeneously distributed among the schools and years of study using stratified random sampling. The number of students per department was divided into the number of years of study. The students in three nursing schools in the 2011–2012 academic year who agreed to participate in the study were included in the sample (n = 330). 3.2. Instruments 3.2.1. The Personal Information Form This form was prepared by the researchers and included questions on the students' age, gender, grade, parental education level, parental occupation, income status, liking of nursing profession, their opinion about own academic success. 3.2.2. The Study Process Questionnaire (R-SPQ-2F) This is a five-point Likert scale developed by Biggs et al. (2001). Its Turkish validity and reliability were analyzed by Batı et al. (2010), and it includes questions on the students' learning approaches and styles. The total score for each approach varies from 10 to 50. The Cronbach's alpha value for the scale was found to be 0.77 for the deep approach and 0.80 for the superficial approach. The scale consists of 20 items: five items for two subscales with two determinants for each. These subscales are the deep approach (DA) and the superficial approach (SA). The DA consists of deep motivation (DM) and deep strategy (DS) determinants. The SA consists of superficial motivation (SM) and superficial strategy (SS) determinants (Batı et al., 2010). 3.2.3. The Motivation Resources and Problems Scale This is a five point Likert scale developed by Acat and Köşgeroğlu (2006). It has 24 items in three subscales: internal motivation (IM), negative motivation (NM) and external motivation (EM). Internal motivation is defined as the doing of an activity for its inherent satisfactions rather than for some separable consequence. External motivation is a construct that pertains whenever an activity is done in order to attain some separable outcome. Negative motivation is the state of lacking an intention to act (Ryan and Deci, 2000). The score for each subscale is calculated by using the arithmetic mean of the scores obtained from the subscale items. The average of the scores obtained for the three subscales yields the participants professional learning motivation scores. The internal consistency alpha coefficient was found to be 0.82. The


internal consistency coefficient was found to be 0.84 for the IM subscale, 0.69 for NM subscale and 0.68 for the EM subscale (Acat and Köşgeroğlu, 2006).

Table 2 The comparison of the “Motivation Resources and Problems Scale” between educational systems. MRP Scale

Educational system

n

Mean

SD

F

p

Internal motivation

Integrated PBL Traditional Integrated PBL Traditional Integrated PBL Traditional Integrated PBL Traditional

149 119 81 149 120 81 149 119 81 149 120 81

38.1 41.6 36.6 23.5 21.7 22.5 19.0 22.4 18.2 80.7 85.7 77.3

7.3 7.9 7.9 5.5 4.6 4.9 3.8 3.0 4.9 10.0 10.2 11.7

12.181

0.000

4.193

0.016

40.280

0.000

16.341

0.000

3.3. Data Analysis SPSS 16.0 statistical program was used for statistical analyses. Descriptive statistical methods (percentage distributions, averages and standard deviations) were used for data analysis. Independentsamples t-test and one-way ANOVA (variance) analysis were used to compare the students, and Scheffe's test was used for post-hoc analysis. Pearson's correlation test was used to determine the relationship among the variables, and multiple regression analysis was used to determine the variables that affect the study process, and motivation resources and problems. The threshold for statistical significance was p b 0.05.

3.4. Ethical Considerations Approval to conduct the study was obtained from the heads of the institutions where the study was conducted. Informed consent was obtained from the students who were willing to participate in the study. The purpose of the study was explained to them and they were assured of the anonymity and confidentiality of their responses to the questionnaires.

4. Results 4.1. Sociodemographic Data Of the students, 42.6% (n = 149) were studying in an integrated educational system, 34.3% (n = 120) were studying in a PBL education system, and 23.1% (n = 81) were studying in a traditional educational system. Of them, 90 (25.7%) were in their first grade, 86 (24.6%) were in their second grade, 83 (23.7%) were in their third grade, and 91 (26%) were in the fourth grade. Of the students, 70% were female and 30% were male. Of, 178 (50.9%) stated that they like their nursing profession somewhat, and 269 (76.9%) regarded themselves as successful. However, 68.9% of the students were dissatisfied with their educational system.

Table 1 The comparison of the “Study Process Scale” between educational systems. R-SPQ-2F

Educational system

n

Mean

SD

F

p

Deep approach

Integrated PBL Traditional Integrated PBL Traditional Integrated PBL Traditional Integrated PBL Traditional Integrated PBL Traditional Integrated PBL Traditional Integrated PBL Traditional

149 120 81 149 120 81 149 120 81 149 120 81 149 120 81 149 120 81 149 120 81

31.3 34.2 31.1 15.4 16.8 15.6 15.9 17.5 15.6 28.4 27.5 29.9 13.7 12.5 14.0 14.7 15.1 15.9 59.78 61.7 61.1

5.5 5.5 7.5 3.2 3.1 5.1 2.9 2.8 3.2 5.5 6.0 6.3 3.5 3.2 3.7 2.7 3.3 3.5 7.6 5.9 9.6

9.378

0.000

4.783

0.009

12.747

0.000

4.064

0.018

6.309

0.002

3.653

0.027

Deep motivation

Deep strategy

Superficial approach

Superficial motivation

Superficial strategy

Total

2.272

0.105

15

External motivation

Negative motivation

Total

4.2. Analyzing Nursing Students' Study Process, Motivation Resources, and Motivation Problems A statistically significant difference was found between the scores of the students on the subscales of study process by educational systems (p b 0.001) (Table 1). Scheffe's post-hoc test was used to find which educational system caused this difference. A statistically significant difference was found between the PBL and integrated-system score averages (p = 0.009) in the DM subscale, between the PBL and traditional system score averages (p = 0.018) in the SA subscale, and between the integrated system and traditional system (p = 0.027) in the SS subscale. A statistically significant difference was found among the total scores (p = 0.000) and the scores of the subscales of the MRP Scale based on their educational systems (Table 2). Using the Scheffe's posthoc test, the significant differences were between the PBL and integrated system, and PBL and traditional systems total and sub-scale scores of MRP (p b 0.001). A positive significant correlation was found between the total score on the R-SPQ-2F Scale, MRP Scale and subscales; between the DA, DM, DS subscales and the total score on MRP scale and the scores of IM and NM subscales. A negative significant correlation was found between the SA, IM and NM subscales; between SM, IM and NM subscales; and between SS and IM subscales (Table 3).

4.3. The Nursing Students' Study Process, Motivation Resources, Problems and Demographic Characteristics Regression analysis found a moderately (R = 0.604) significant interaction between the variables and the score averages of the students on the DA subscale (F = 12.080, p = 0.00). These variables only explain 36% of the students' study process. The standardized regression coefficient (β) indicated that only the variables of the maternal education level (β = − 0.234), liking the nursing profession (β = 0.478), and

Table 3 The correlation of the “Study Process Scale” and “Motivation Resources and Problems Scale”. MRP total

R-SPQ-2F total Deep approach Deep motivation Deep strategy Superficial approach Superficial motivation Superficial strategy ⁎ Significant at p b 0.001. ⁎⁎ Significant at p b 0.05.

Internal motivation

External motivation

Negative motivation

r

r

r

r

0.314⁎ 0.401⁎ 0.347⁎ 0.387⁎

0.176⁎ 0.468⁎ 0.431⁎ 0.420⁎

0.219⁎ −0.166⁎ −0.163⁎ −0.136⁎ 0.456⁎ 0.508⁎ 0.298⁎

0.233⁎ 0.389⁎ 0.309⁎ 0.409⁎

−0.015 −0.088 0.070

−0.262⁎ −0.329⁎ −0.131⁎⁎

−0.106⁎⁎ −0.244⁎ 0.071

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Table 4 Results of multiple regression analysis of the “Study Process Scale”, “Motivation Resources and Problems Scale” and demographic characteristics. R-SPQ-2F

Age Gender Grade Mother's education level Father's education level Mother's occupation Father's occupation Income status Liking of nursing Educational system Academic success R R2 F p

Deep approach sub-scale β

Surface approach Sub-scale β

−0.077 −0.042 0.087 −0.234⁎ 0.083 −0.031 −0.009 0.030 0.478⁎ 0.109⁎⁎

−0.082 0.027 0.073 0.018 −0.069 0.188⁎⁎ 0.153⁎⁎ −0.068 0.096 0.046 −0.183⁎⁎ 0.335 0.112 2.663 0.001

−0.073 0.604 0.364 12.080 0.000

MRP β −0.114 0.016 0.034 −0.085 0.127 0.129⁎⁎ −0.138⁎⁎ −0.011 −0.052 0.127⁎ −0.002 0.259 0.067 1.411 0.134

R-SPQ-2F, Study Process Scale; MRP, Motivation Resources and Problems Scale; β, standardized regression coefficient; R2 = variance. ⁎ Significant at p b 0.001. ⁎⁎ Significant at p b 0.05.

the educational system (β = 0.109), significantly affect the DA subscale scores of nursing students (Table 4). Regression analysis found a moderately (R = 0.335) significant interaction between the variables and the score averages of the students on the SA subscale (F = 2.663, p = 0.00). These variables only explain 11% of the students' study process. The standardized regression coefficient (β) indicated that only the variables of the mothers' occupation (β = 0.188), fathers' occupation (β = 0.153) and academic success (β = −0.183), significantly affect the SA subscale scores of nursing students (Table 4). Regression analysis showed a low (R = 0.259) insignificant interaction between the variables and the score averages of the students on the MRP Scale (F = 1.411, p = 0.134). These variables explain approximately 7% of the dependent variable of nursing students' motivation resources and problems. The standardized regression coefficient (β) indicated that only the variable of the maternal (β = 0.129), and paternal (β = −0.138) occupations and education systems (β = 0.127) significantly affects nursing students' motivation resources and problems (Table 4). 5. Discussion A significant difference was found between study process and educational systems. This difference was determined to favor the students in the PBL system and those who adopt the deep-learning approach. Similarly, Tetik et al. (2009) found that students in the PBL system adopt the deep-learning approach, and that the PBL curriculum is more useful for developing the deep-learning approach than those of hybrid and integrated systems. Mohamed Ali and El Sebai (2010) indicated that the PBL method is a commonly used and effective approach for nursing students to acquire deep learning. Factors such as internal motivation, critical thinking, problem-based education, active learning, written and oral presentations, participation in teamwork, sufficient time to study and metacognitive awareness play an important role in helping students to adopt the deep-learning approach (Beccaria et al., 2014; Mansouri et al., 2006; Martyn et al., 2014). PBL aims to develop the deep-learning approach. In the PBL system, students are expected to take responsibility and implement the principles of self-learning (Hung et al., 2007). However, nurse educators must help students develop appropriate strategies for coping with and engaging in the PBL process (Yuan et al., 2011). In traditional and integrated educational

systems, on the other hand, the information that students need is provided by the educator (Strobel and van Barneveld, 2009). Therefore, to acquire deep-learning approaches, students in traditional and integrated educational systems should be encouraged to take responsibility for subjects that can be learnt by researching topics as PBL system rather than being given available information. Providing freely available information to students can cause them to use superficial learning rather than deep learning because the students do not make any effort to learn. Therefore, learning approaches score averages for PBL are expected to be higher than others. A significant difference was found between motivation and educational systems. This difference was found to be caused by PBL in the total score and internal and negative motivation subscales, and by PBL and the integrated system in the external motivation subscale. This study found the intrinsic motivation and negative motivation of students in the PBL system to be higher than the others. For students in traditional educational systems, this situation is reversed. Motivation is important for academic success. A significant part of the nursing students' goal of effective learning, self-development and management of problems that affect their academic success is explained by the internal, external and negative motivation theory developed by Ryan and Deci (2000). Curiosity, the need to know, the desire to be successful, internal motivation, and the desire for self-development, results from the reaction to individual internal needs (Özlü Karaman et al., 2014). When students use their instinct for learning, their academic success level will inevitably increase. However, to promote this desire for learning, information should be given that arouses students' curiosity. Curiosity is only aroused when students consider information necessary. Therefore, educators should provide daily life-related information to students in both clinical environments and classrooms. Educators can motivate students to increase their personal efforts by boosting their eagerness to learn. Thus, educators should use active-learning strategies while giving information to students. For example, it cannot be expected that presenting information using speech which is ordinary, monotone and not selfrenewing, generates motivation. Sangestani and Khatiban (2013) found that learning progress in PBL group was significantly more than the lecture-based learning group. PBL improved the application of theory lessons clinical practice, increased learning motivation and enhanced educational activity in class. Also, Hwang and Kim (2006) indicated that the level of knowledge in the PBL group was significantly higher than that of students in the traditional lecture group, and that learning motivation was significantly higher in the PBL group. In their study, students in the PBL group gained more knowledge and had higher motivation toward learning compared to students in the lecture group. Nilsson and Warrén Stomberg (2008) stated that the main motivation factor was extrinsic and goal oriented; namely becoming a nurse. They found that nursing students mentioned intrinsic motivation factors as an explanation for their degree of motivation. Their results highlight the need for understanding the students' situation and their need of tutorial support. Çelik et al. (2014) found that the internal and external motivations of Turkish nursing students were high, and their negative motivation was low. Köksal and Yurttaş (2015) found that their internal motivation levels were high, and their external motivation levels were above average. Özlü Karaman et al. (2014) found that negative motivation levels were high. Demirel and Turan (2010) found that the students who received PBL were more satisfied with their learning levels, enjoyed learning and had higher motivation levels. They also found that the use of unstructured and unique problems increases students' motivation levels, helping them to develop responsibility and autonomy. In accordance with this study, the literature (Demirel and Turan, 2010; Köksal and Yurttaş, 2015; Özlü Karaman et al., 2014) has shown that nursing students have higher levels of intrinsic motivation. Educators should imbue students with the idea that they are not only students during their undergraduate education, but should remain students throughout their lifetimes. To keep pace with developing technology and increasing amounts of


information, nurses need to have higher levels of intrinsic motivation. Furthermore, the organization of the teaching program needs to be developed in co-operation with the students to match the content in courses with the students' different degree of motivation during their academic years (Nilsson and Warrén Stomberg, 2008). Ryan and Deci (2000) argue that students' internal motivation should be high in terms of willingness to learn, and that knowing the external motivation resources and transforming them into internal motivation resources are important ways to increase professional motivation. This study suggests that in the PBL system, educators give problems that will lead students to learn. These problems constitute the external motivation resources, and the need to know and wish to be self-sufficient constitutes the internal motivation of the students. In fact, the cognitive-learning theories emphasize that the learner should take the responsibility for learning and actively participate in the learning process. Students who choose their own actions and positively direct themselves in self-learning have more control and responsibility for their learning (Duman and Şengün, 2011; Levett-Jones, 2005). In our study, we found that when the internal motivation and negative motivation increases, the deep-learning approach increases. Also when the external motivation increases, the superficial approach increases. Students who adopt the deep-learning approach aim to understand. Therefore, their internal motivation is higher. These results indicated that the superficial approach is based on external motivation or the fear of failure. Linares (1999) and Yu (2002) stated that nursing students with a high internal focus of control are better prepared for self-learning than the nursing students with a high external focus of control. Khalaila (2015) found intrinsic motivation to be a significant mediator in the relationship between self-concept and academic achievement. Aktaş and Karabulut (2016) indicated that academic motivation increased as the quality of their clinical learning environment improved. As the literature shows, motivation and learning approaches are closely related. This study found that variables such as liking their profession, maternal education, and the type of educational system positively affected the nursing students' learning approaches. Another study reported that the characteristics of the education system, the learning environment, teachers, and academic and social self-perception are also variables that may affect learning approaches (Pimparyon et al., 2000). Arslan et al. (2015) found that the sociodemographic characteristics like grade, income and family type affect deep learning. They also found that grade, gender, maternal working status, the previous educational establishment and appropriate study environment affect superficial learning. James et al. (2011) and Hallin (2014) determined that learning preferences were not influenced by demographic factors such as gender and age group. Most students enter universities by coincidence rather than because of their wishes or abilities, and they may choose professions in which they do not want to work in order to be able to attend university. Students who are familiar with the working conditions and fields of study in a profession and choose that profession willingly desire to learn in order to perform their role in that profession properly, and this affects learning positively. In nursing education, the professional consciousness of the students is expected to increase as their age and grade increase, and this is expected to affect learning. In our study the regression analysis showed the educational system affected the students' deeplearning approaches. The literature supports the idea that PBL affects the learning approach (Alghasham, 2012; Baker et al., 2007). This study found that the variable of parental occupation and education systems had a significant effect on the nursing students' motivation resources and motivational problems. We also found that gender does not affect motivation, which is important for this profession. Men have recently started to work in this profession, which was long regarded as a profession only for women; this finding shows that gender discrimination has fallen in this profession. Other factors have been reported to affect motivation resources, for example, the reason

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for choosing and liking the nursing profession (Köksal and Yurttaş, 2015; Çelik et al., 2014). The professional motivation levels of individuals are expected to be high when they work in the field of their choosing and according to their own wishes and abilities, and to be low when they work in other undesired fields. Society's perspective on the profession is also considered to affect motivation. This study found that the study process, and motivation resources and problems of nursing students were affected by different educational systems. The effect on the study process, and motivation resources and problems, resulting from a particular educational system, illustrates the defects of that education system. Teachers of nurses must ensure that students gain a deep-learning approach, have high internal and external motivation, and lower negative motivation. However, in our study these are the opposite, especially in the integrated education system. It is important that teachers recognize their students' learning approaches, use active-learning strategies to support students' learning, and plan applications to motivate students in all education systems. 6. Limitations The biggest strength of this study is that it was conducted in three schools with three different educational systems using a stratified sampling method rather than studying a small sample and a single educational system as other studies have done. This study has a few limitations. Our study's limitation is that of a potential bias in sampling due to the lack of random selection. This is a cross-sectional study. Longitudinal studies that analyze the study process and motivation resources of students from the first to the last grade more effectively determine the development and change of students in educational systems. 7. Conclusion We concluded that the learning approaches and the motivation resources of students in nursing-education programs were affected by different educational systems. This study determined that the PBL educational system improves nursing students' deep-learning approaches and positively affects their motivation resources more effectively than other educational systems. However, further studies examining the effect of the relationship between learning approaches and motivation resources in different educational systems should be conducted. References Acat, M.B., Köşgeroğlu, N., 2006. Motivation's resources and problems scale. Anatol. J. Psychiatry 7, 204–210. Aktaş, Y.Y., Karabulut, N., 2016. A survey on Turkish nursing students' perception of clinical learning environment and its association with academic motivation and clinical decision making. Nurse Educ. Today 36, 124–128. Alghasham, A.A., 2012. Effect of students' learning styles on classroom performance in problem-based learning. Med. Teach. 34 (1), S14–S19. Alkhasawneh, I.M., Mrayyan, M.T., Docherty, C., Alashram, S., Yousef, H.Y., 2008. Problembased learning (PBL): assessing students' learning preferences using VARK. Nurse Educ. Today 28 (5), 572–579. Al-Kloub, M.I., Salameh, T.N., Froelicher, E.S., 2014. Nursing students evaluation of problem based learning and the impact of culture on the learning process and outcomes: a pilot project. Nurse Educ. Pract. 14 (2), 142–147. Andreou, C., Papastavrou, E., Merkouris, A., 2014. Learning styles and critical thinking relationship in baccalaureate nursing education: a systematic review. Nurse Educ. Today 34 (3), 362–371. Arslan, S., Ceylan, B., Koçoğlu, D., 2015. Nursing students' approaches to learning and studying. J. Hacet. Univ. Fac. Nurs. 2 (2), 59–69. Baker, C.M., Pesut, D.J., McDaniel, A.M., Fisher, M.L., 2007. Evaluating the impact of problem-based learning on learning styles of master's students in nursing administration. J. Prof. Nurs. 23 (4), 214–219. Batı, A.H., Tetik, C., Gürpınar, E., 2010. Assessment of the validity and reliability of the Turkish adaptation of the study process questionnaire (R-SPQ-2F). Türk. Klin. J. Med. Sci. 30 (5), 1639–1646. Beccaria, L., Kek, M., Huijser, H., Rose, J., Kimmins, L., 2014. The interrelationships between student approaches to learning and group work. Nurse Educ. Today 34 (7), 1094–1103. Bengtsson, M., Ohlsson, B., 2010. The nursing and medical students motivation to attain knowledge. Nurse Educ. Today 30 (2), 150–156.

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